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Mystery After the Health Care Ruling: Which States Will Refuse Medicaid Expansion?

The Supreme Court ruling allows states to decline the Medicaid expansion included in the Affordable Care Act without losing federal money for their existing Medicaid programs. If the 26 states that challenged the law opt out, an estimated 8.5 million fewer people would be covered by Medicaid.

An officer stands outside the Supreme Court as media and the public gather to hear the Supreme Court's decision on the health care law on Thursday in Washington, D.C. (David Goldman/AP Photo)

See our interactive map of how health reform could expand Medicaid in each state.

For many people without insurance, a key question raised by the Supreme Court's decision today to uphold the Affordable Care Act is whether states will decline to participate in the law's big Medicaid expansion.

Although the court upheld the law's mandate requiring individuals to buy insurance, the justices said the act could not force states to expand Medicaid to millions by threatening to withhold federal funding.

Republican leaders of some states already are saying they are inclined to say thanks, but no thanks.

Tom Suehs, the Texas Health and Human Services Executive commissioner whose state could cover an additional 1.8 million people by 2019, praised the court for giving "states more ability to push back against a forced expansion of Medicaid. The court clearly recognized that the Affordable Care Act put states in the no-win situation of losing all their Medicaid funding or expanding their programs knowing that they would face billions of dollars in extra costs down the road."

Stanford University health economist Dr. Jay Bhattacharya wrote on Stanford's medical school blog that some states may opt out. "Cash-strapped states will almost certainly consider this option since they will ultimately be on the hook for financing at least a portion of this expansion," he wrote. "If enough states decide to deny the Medicaid expansion, this may substantially reduce the ability of ACA [the Affordable Care Act] to expand insurance coverage."

Medicaid is a joint state-federal program that provides health coverage to the poor and disabled, with states putting up a portion of the money and the federal government funding the rest. Each state's matching percentage is based on per capita income.

According to a separate Kaiser foundation report, "Medicaid currently provides health coverage for over 60 million individuals, including 1 in 4 children, but low parent eligibility levels and restrictions in eligibility for other adults mean that many low income individuals remain uninsured. The ACA expands coverage by setting a national Medicaid eligibility floor for nearly all groups."

"Specifically, the federal government will assume 100 percent of the Medicaid costs of covering newly eligible individuals for the first three years that the expansion is in effect (2014-16). Federal support will then phase down slightly over the following several years, and by 2020 (and for all subsequent years), the federal government will pay 90 percent of the costs of covering these individuals. According to CBO, between 2014 and 2022, the federal government will pay $931 billion of the cost of the Medicaid expansion, while states will pay roughly $73 billion, or 7 percent."

States that challenged the law argued that it was coercive to require them to either expand Medicaid or risk losing all Medicaid funding, a practical impossibility given the size of the program in most states. The court ruled that while it was constitutional for Congress to offer states money to expand Medicaid, it could not take away funding for their existing program if they declined, according to SCOTUSblog.

Immediately after the ruling, some Republican state officials said they were inclined to reject the new federal money, although there has been no deadline set for doing so.

In Missouri, according to The Associated Press, "House Majority Leader Tim Jones says the Republican-led Legislature will not consider the expansion. Republican Lt. Gov. Peter Kinder called the Medicaid expansion a 'break-the-bank provision.'"

After all, Alabama Gov. Robert Bentley said, "The health care law is an overreach by the federal government that creates more regulation, bureaucracy, and a dramatic increase in costs to taxpayers."

And South Dakota's attorney general, Marty Jackle, was likewise blunt: "I am relieved that the Act's Medicaid expansion has been declared unconstitutional and has been significantly limited by the Court."

That said, rhetoric does not always translate to action. Many Republican governors said they would not accept funds from the 2009 stimulus package, but they ended up taking the money in the end. Three governors, in Florida, Wisconsin and Ohio, turned down money to build a high-speed rail line. Former South Carolina Gov. Mark Sanford tried to turn down federal education stimulus money, but his state Supreme Court rejected that. And former Alaska Gov. Sarah Palin rejected some state energy funding, but her Legislature overruled her.

32 comments

I feel like the biggest story, here, is how many people have no clue about…well, anything.

We could start with the simple fact that health insurance is unrelated to healthcare, except in their positions in the dictionary. There’s the problem with people calling it socialism for the government to package up and sell us to the insurance companies (it’s obscene, but not socialist).

There’s also the odd idea, in the last paragraph, that Presidents have the authority to repeal anything. If Romney were in power, he can write a bill and propose it to Congress. That’s it.

Not to dive too far off-topic, but the problem in this country isn’t insurance. It’s that a broken arm sets you back twelve thousand bucks for some C-student to do what a random Cub Scout would do for free: Set the bone and tell you to buy aspirin.

Why? The AMA says so, limits the supply of doctors, and nobody can argue because everybody has insurance to cover the cost. When a doctor can lose his license for getting caught offering someone a discount, but is protected if he operates on the wrong lung, there’s a problem deeper than “the uninsured.” When the guy missing his good lung sues, the doctors whine that it’s driving up their costs to pay for malpractice insurance. (Hint: Maybe doctors should be getting stuff right, rather than insuring against mistakes and blaming the victim.)

Drive the costs down by eliminating the parasitic entities and crappy doctors, and we can all afford healthcare except for the most horribly ill. Those people, we can put on a government program with my blessing.

Instead, the insurance companies just got a sweetheart deal of an unlimited supply of healthy customers to pay their bills for no work and at no cost.

One thing is baffling me, though: Since the insurance industry is now working at the behest of the government (because it’s forcing us to become customers), are they obligated to respect the Bill of Rights? Is it possible that we now have a right, for example, to “confront our accusers” when our rates go up for whatever reason? Can they be prevented from charging different rates (discriminating) based on race or religious belief, despite actuarial tables telling them that some group has a higher risk for some problem?

Probably not, but they should be. They’ll be governing us at least as much as Washington does. And without an obligation to protect our rights, they won’t.

John, the insurance companies, prior to the ACA, had the right to deny YOU health insurance for what ever reason they wanted to. Now they don’t. Furthermore, a high percentage of their premiums have to be spent on health care - not administration - if they have to spend 90% on health care then it doesn’t do them a whole lot of good to raise premiums, does it? Unless they really have to.

So, rather than spend all your time making up negatives that just don’t exist, try to find ways to improve the ACA just as Social Security and Medicare were improved over time.

Like all programs induced, created, intiated or otherwise a product of our govt this will produce costs, waste, fraud and restrictions beyond anything you have imagined. Three programs that fit the above are Social Security (of which I am a recipient), Medicare (of which will be a joke before I die), and SNAP the food stamp program that presently “SNAP parties” are being held in senior centers to explain to them how they can qualify for a SNAP card no matter what their circumstances. If you really do not think this govt is intruding obscenly into your life now, please talk to me in 10yrs.

Charles, problems with SNAP but not with the copious subsidies given to the affluent? Perhaps we can start by eliminating the $131 billion/yr subsidies to affluent home owners. 3/4th of the home mortgage interest deduction goes to those who make more than $108,000 per year; half goes to those who make more than $151,000/yr, and 31% to those making more than $260,000/yr.

Nor does this count the $31B per year subsidy given by the deduction for residential property tax, or $50B/yr for exclusion of housing capital gains.

And everyone ought to get the same subsidies for health insurance that businesses get, right? Those now come to $177B per year, and will be a trillion dollars over the next five years. That’s about $945 per employee per year.

ARIZONA—but I don’t think most people will stand for it. Whoever does will lose doctors to other states, and so much more. The governor said it was such a burden on our state. And then decided that adults without children were an easy target to deny medicaid coverage to. So I think she’d like the whole welfare state to come back. Young women would have to give birth to get health coverage. When in fact I believe the main reason she and her puppet-masters wanted this was to whine about expanding medicaid coverage for soley political reasons.

I am questioning which way the newly-admitted tax will be treated on our individual income tax returns? Will it be treated the same way the Social Security TAX is treated (as something that NO INDIVIDUAL can DEDUCT) or will it be treated as another cost that can be itemized, thus being deducted from income before calculating taxes due, just like mortgage interest?

The administration had claimed it was not a tax when they got it passed, yet used that as a trump-card argument when things got rough in the Supreme Court arguments. Now that it was upheld only as a TAX, which way will it be treated on our tax returns?

Since this consequence was not planned at the inception, I suspect the Supreme Court just gave us a new itemized deduction for those who can benefit from itemizing.

How will this possible ‘wrinkle’ impact the tax collection that is now further burdened with paying for the added costs?

“If Romney were in power, he can write a bill and propose it to Congress. That’s it.”

You sure? I recall a certain (recent) President refusing to prosecute/deport certain illegals “Because it’s the right thing to do.” If Romney wins, he could just as easily refuse to prosecute people who don’t abide by the mandate “Because it’s the right thing to do.”

JJ, interest question. I read on the Supreme Court decision today, that you pay the Tax to IRS as an Income Tax. Wonder if thats true and perhaps it is questionable RIght Now as to any deductions on it. OR if it is just a strait Income of Earnings, which could harm some people if they are on any “maxiumum earnings” plan like Medicaid.

So when a state refuses the additional Medicaid, what happens to the people who would have been eligible?

They are forced by the mandate to purchase over-priced under-insurance and spend upwards of 30% of their household budget when they are already unable to keep food on the table, heat in the house or even a house.

You stated “if they have to spend 90% on health care then it doesn’t do them a whole lot of good to raise premiums.” Total fallacy. First of all, it’s 80%. Second that 80% only has to be spent on anything the insurers can get defined as “clinical services or activities that improve health care quality.” So it’s actually a ‘cost plus’ system and HHS has already approved as “activities that improve health care” such things as: intrusive ‘health care managers’ that deny medically prescribed procedures; additional administrative functions to “detect fraud” - just a way around the requirement to stop recision; development and implementation of new diagnostic codes used for claims denial, etc.

So for every $1.00 the insurers can get HHS to approve, they can charge you $1.20.

There are no cost controls on insurance premiums. The most HHS can do is ‘send it back to the insurance companies for review.’ Then the states are in charge of cost control. The problem there is that it’s a revolving door between the state HHS and the insurance companies themselves.

The only answer is Single Payer. The Obamabots who what to give us their over-simplified platitudes, vote the corporate servants back in and then go relax on the couch thinking they have done their part are the worst enemies of needed change.

No, those who fall in the 101-133% of FPL will receive federal subsidies to buy health insurance if their state does not participate. It is a refundable, advance credit that will likely cover the entire cost of their insurance. They’ll still be better off with the ACA than without it.

Many Republican run states will loudly turn the Medicaid expansion down but then almost all will quietly come around to accepting it. Their local governments and hospitals will force them to do so.

See, right now we all (as taxpayers and as payers for private insurance) are paying for the medical needs of the uninsured — usually at the highest possible cost. (It costs far more for hospitalization and amputaion of a gangarenous foot or lifetime dialysis, than, say, 10 years of care working with someone with diabetes to prevent foot problems or kidney failure.) For example, Bernalillo County, NM spends $90 million tax money each year to pay for the ER and hospital costs for uninsured. Most all of that money could be saved if almost everyone had some form of insurance coverage.

And the hospitals, while they get additional federal funds as well as state and local tax money to cover care still have to charge patients who have insurance more to make up the difference. Insurers pay the higher rates because they have to — but they in turn have to charge higher premiums to meet those costs. So we pay for those who can’t — or won’t.

John, a lot of what you see as problems are addressed in the law. You are right about one thing: the crappy doctors (and hospitals and medical equipment makers, etc) are a big part of driving up overall health care costs.

Doctors can’t lose their licenses for offering discounts; they may tell you they would to get out of giving you a break but it isn’t true. Doctors are fighting very hard against being held responsible for the wretched quality of care some provide. All that huff about “Tort Reform” and “frivolous lawsuits” is just not wanting to be held responsible for preventable medical errors that kill more than 200,000 Americans each year and take an unimaginable toll in maining and agony. It also runs up medical costs tremendously. Many doctors don’t care because they profit from their errors. They bill you for the procedure and then they bill for all the care needed to try to fix the effects of their mistakes. That is being addressed somewhat in the ACA. There will be penalties for hospitals who don’t reduce the hospital acquired infections and others care caused conditions. If you could get rid of the 5-15% of doctors who screw up repeatedly we would be a lot better off but they have a lot of political clout and are very self protective. The error prone also lie to other doctors about the claims against them so that the others will feel under attack for “nothing” also.

There really isn’t a great shortage of doctors overall. The problem is that too many choose to go into the highly lucrative specialities rather than the more difficult but lower paid primary care. The ACA is working on that. There is loan repayment for those who go into primary care. It has opened up more residencies in primary care areas and it is working on increasing pay for primary care in Medicare/Medicaid. Three of the 4 new Med Schools opened in 2009 have a focus on primary care. That provides more training slots.

Since 50 million people DON”T have insurance you can’t say having people self pay will drive down costs. Nor can most people who need care afford to pay for what is needed even at half today’s costs. What happens is that people won’t see a doctor if they think they can do without until things are so bad they have to. Not being plugged into some system backfires. When nearly half of the people who have diabetes are not even diagnosed we have a problem.

The only way any insurance, public or private, can work is for everyone to pay in and those that need a lot of care are covered. If you don’t need care you still have the security of knowing that you will be able to get needed care if you do. Health care insurance is designed to have a prepayment function to cover normal “maintenence” care like checkups and prevention services because that is the most cost effective way to have a healthy population. It’s no accident that nations with systematized health care, whether totally paid through taxes, partially government subsidized, or mostly private insurance, have longer life spans and better health outcomes than we in the US do.

re your Bill of Rights: the ACA provides for review of insurers raising rates too much. There will be an federal Ombudsman office in each state to help people deal with any problems with insurers. Insurers are not permitted to charge different rates based on health status nor for any perceived higher risk of anyone in any group. That’s what community rating is all about. Insurers will be highly regulated.

You ask a good question about what happens to patients in states that opt out of the expansion. The answer is no one really knows—for the moment. They almost certainly would not be subject to a penalty for going without insurance, but it’s unclear if they would be eligible for federal subsidies. Because the law was crafted anticipating that the Medicaid expansion was mandatory, it envisioned subsidies beginning at 133% of FPL. I’ve asked HHS for a clear answer on this, but I have not received it yet.

But wishful thinking seems to rule - George and Rob are good examples. They are clearly well intentioned, but the fact that so much is hidden in the fine print, while the politicians keep raking in campaign contributions until at least 2014 seems to be the reason for the secrecy and spin. There can be no other reason for that 4 year delay.http://www.opensecrets.org/news/2012/06/obama-health-bill-stands-the-money.html

Sam, it’s actually advertisement that’ll get you booted, but to me, it amounts to the same thing, in my eyes. You can charge what you like, but don’t let anybody know about it. I was told that by lawyers, mind you, not doctors. If I can track down a citation, I will, but notice when the last time you saw a doctor’s rates made public.

As for what situations the law treats, none of them appeared to be treated in the draft that I read. It says that you can’t be denied coverage, but it doesn’t forbid, say, charging more because, say, American Indians are more prone to alcoholism or black men are more susceptable to diabetes. It implies that it won’t happen anymore because of all the healthy people forced to pay in, but there’s no obligation except the moral, unless a late draft changed things.

By the number of doctors, I wasn’t implying a shortage, but I am suggesting that more doctors would demand lower prices to keep them in business, and that some very good medical students are denied licenses to keep the number profitable. It’s a commodity business, for the most part, with most people treating most doctors are interchangeable.

Jason, that’s not repealing. To repeal a law is to strike it from the books, by passing a new law that replaces or nullifies it. If Romney means he won’t enforce the law, then he should say that to show that he actually knows what the President is allowed to do.

(However, enforcement is delegated to the IRS, so even then, it relies on positioning people sympathetic to his “ideals” and making theh case against the few people who would benefit from the program, rather than a guarantee. Also, the IRS—not directly beholden to the President—is getting half a billion dollars to track down people who dare to be healthy without insurance. Could Romney get away with insisting they not use the money to bring money into the Treasury? That’s not very fiscally conservative…)

Everybody, by the way, should head over to supremecourt.gov and pull down a copy of the decision (National Federation of Independent Business v. Sebelius), and at least read through the summary. It’s fascinating stuff, both good and bad, and there’s very little of what you probably think happened.

One specific problem I have with the analysis is that the Justices appear to believe they have an obligation to give laws every benefit in finding them Constitutional, which is how the mandate and penalty system mutated into a tax: The only way the law is within the powers of Congress is if it’s taxation. Personally, I think that’s wrong-headed and directly opposed to the concept of checks and balances, but hey, I wasn’t appointed for life.

Incidentally, I should clarify that I’m against this law because, as I read it, it’s the worst of all worlds, combining awful features from other bad systems. Rather than fixing the industry so that insurance isn’t a necessity for survival, they’re encoding the status quo into law and hoping that the force of law will make us healthier.

I would have supported just about any alternative. This, though, is a mess, and sets any real progress back decades.

For those who don’t understand what the ACA is about…here’s a synopsis of the bill:

1. Lets millions of young adults stay on parent’s insurance until age 26
2. Ends insurance company power to cap the amount of care a person can receive in their lifetime
3. Stops insurance companies from canceling coverage when someone gets sick
4. Lowers the cost of care of those on Medicare and helps seniors save money on their medication (already doing that)
5. Requires insurance companies to cover preventive services like mammograms free of charge
6. Strengthens and protects Medicare by increasing penalties for fraud
7. Stops insurance companies from denying coverage to children with pre-existing conditions
8. Ends insurance company power to jack up rates without justification
9. Provides Americans with rebates from insurers who spend too much on CEO bonuses and ads
10. Gives tax credits to small business owners so they can afford to offer quality health care for their employees
11. Builds and improves hundreds of community health centers
12. Gives hard-working Americans tax credits so they can afford insurance premiums in 2014
13. Ends discrimination against adults with pre-existing conditions beginning in 2014 AND
14. Prevents insurance companies from charging women more than men and overcharging those who need care the most beginning in 2014.

It all looks like a win-win situation to me….too bad most people don’t see it that way.

Didi: Thanks! As usual, we have a plethora of opinions posted here, but your post clarifies what WAS accomplished through the wildly contentious process in passing the ACA - despite the efforts of the opposition (including blue dogs) to kill it. What irks me the most are those who continue to insist that we’re Obamabots if we didn’t hold out for single payer. Utterly unrealistic since anyone with functioning synapses realizes that line in the sand would have tanked the whole thing.

Legislation is subject to modification. This “Obamabot”, along with millions of others, will continue to work towards getting single payer, as well as fixing other numerous flaws in this huge landmark piece of legislation. An instantaneous “perfect world” resides only in the minds of those who haven’t enough legwork to humble them.

I still think Texas and Arizona will opt out on Medicaid expansion. They both have huge minority underclass populations and mean-spirited track records.

JJ’s question about tax treatments is interesting. I hope Congress takes this opportunity to straighten out the tax situation (but I am not hopeful). There seems little sense in collecting taxes for health care with one hand and giving out deductions with the other. The cost of tax-exempt health benefits to employers in FY11 will be $177 billion, and it will be a trillion dollars over the next five years. This works out to $1250 per employed American, or $564 per capita per year. And those who are self-employed get only a fraction of the benefit, which is grossly unfair.

If employers and their workers are getting this taxpayer subsidy, then everyone should too. In a 2009 op-ed in USA Today, Mitt Romney wrote that the cost of his insurance reforms in Massaschusetts was, after savings, about $350 million/yr. That works out to $53 per state resident per year, which hardly sounds onerous.

Didi, I can’t speak for anybody else, but there are two reasons I don’t see it that way, personally.

First, health insurance is NOT health care. Lack of access to insurance isn’t the problem. Inaccessible and poor care is.

Second, this may be the intention of the law, but it’s hard to figure out how it’s implemented in page after page after page in the law, which I recommend reading (in parts over time, obviously) to see how convoluted and unclear it is. Experience in this country shows, that unless it’s stated explicitly in one sentence, the intent will be avoided through loopholes and doublespeak. I’d be willing to bet this bill was drafted originally by insurance companies and their lobbyists.

The real problem is that only one of your points (#11) solves a REAL problem. The rest of them (try to) treat the abuses of an inessential, inherently abusive industry, insurance. And insurance is only necessary because care is priced out of everybody’s budget (because doctors are irresponsible and overpriced, fast food is absurdly cheaper than vegetables, and/or Americans are litigious cretins, depending on who you ask—I favor the first two and include the third for completeness).

Again, here’s the health care legislation we really need: “Provide health care competitively, if you’re trained to do so.” Fits on a bumper sticker (if inelegantly), so there’s no miscommunication, and it solves thirteen out of fourteen of your points by removing the need for insurance.

John, I partly disagree—insurance *is* a problem. If you’re ever tried to live without health insurance, you quickly find out that the care available to you is quite limited. A simple visit to a doctor can easily cost over $150, you settle for whatever medications are cheaply priced, you suffer in pain with conditions for which the medication is too costly or diagnostic tests too expensive (which usually means almost *all* tests). Try going to a doctor and describing some nebulous set of symptoms, and ask them to help you, except they can’t do any testing at all.

It all sounds so wonderful - Utopia…I can have all I want for a mere fraction of the “actual” cost of my care - or for “free”.

I am entitled to all I want, deserve all I want, and should get all I want. Let’s throw in “for Free” because it sounds so good. And, if I don’t get exactly what I want - it is someone elses fault. What a wonderful concept.

Insurance companies will be forced to “do the right thing”, the rich will be forced to pay their “fair” share and everyone will be happy….once they get used to this idea of free.

Heck, I can get hundreds of thousands of dollars in medical care for a mere fraction of the cost (insurance). Insurance companies are in business to make money, not b/c they care for us. It’s like one giant ponzi scheme.

America has been living a lie for far to long. We are a nation of debtors - wanting, no deserving more than we are willing to WORK for. So we borrow and borrow and borrow.

In this country, we used to pay with cash. If we didn’t have the money - we saved for it. Every family member didn’t have a car, computer, tv, cell phone and/or credit card. We got special gifts at Christmas and our birthdays - now we buy for no other reason than we WANT.

All that money for want comes from somewhere - look at the NATIONAL DEBT. The government doesn’t owe that - WE DO. We are America!

Take every last pennie from the 1% and it won’t make a dent in the National Debt.

Life isn’t fair and things aren’t free. We aren’t all exactly the same and someone has to pay for everything. There are no free rides America.

Why do we buy into the continual lies that politicians spew? They tell us what we want to hear. Lie, cheat and steal and we “overlook” that because we want - what we want and maybe this time we will get it!

Look to the 1%ers. The bottom half is full of Doctors, the upper half owns the medical/healthcare/insurance industry. Most are members of the GOP. They don’t want Obama care because they will loss money somewhere. Namely customers that have to pay over inflated rates. The plan would insure people up to the 30k earning level. Read the numbers, that would cost them a hell of a lot of money. Why because over 50% of the bottom 80% fall in that group.

The pie-in-the-sky list you post is straight from BHO campaign lit - not noted for its accuracy or context.
There are already many carveouts and exemptions for a variety of groups and special interests. To say nothing of the fact that people can opt out for about $55/month at the low end and remain uncovered.
So.
Those people, when they get sick or injured, will still be a load on the system that others pay for.
Geez. Get a clue.
Set down the Kool-Aid. The benefits you mention are over-stated and would only apply if we had single-payer.
What we now face is the prospect of rapacious health insurers, who answer to shareholders not patients, getting 30-40 million new customers.
Many of whom had been their clients previously and detest their value system.
Insurers who are generous political donors, and will now further cement their role running much of health care policy in this country.
This is awful news. And diverts us from a better goal of health care available to anyone, without profit or politics in the way.

David, to clarify, I’m saying that insurance is a (poor) solution to a deeper problem. You even say it yourself: Just gazing upon a doctor costs more money than I have in my pocket right now.

The difference is that you’re assuming that’s the case because it must be, and that insurance is therefore critical. I see it as an abomination and insurance is just a “patch,” on the other hand, to the cost problem. So if some people can’t afford insurance, the right solution isn’t to make insurance affordable (perhaps we should get insurance to cover our insurance premiums…), but remove the forces that make insurance such an artificial necessity.

Appropriately for a flawed medical industry, the ACA treats symptoms our previous “treatments” have created, rather than treating the disease, in other words.

You people are stupid the president can stop this anytime he wants with his dictator power called executive order which has same power of law. A president has the power to make any laws he wants without congress. Heck Obama is first president that has the power to declare war without congress and with ndaa bill he signed into law while you were celebrating the new year the goverment has the power to detain and hold anyone even kill them and torture them without trial if you combine all the powers of the patriot act with it Obama is bushes twin brother when it comes to destroying the constitution and Romney won’t care about the constitution either. These brain dead morons you keep electing are nothing but terrorists.

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